This document provides protocols for treating allergic reactions ranging from mild to severe. It outlines signs and symptoms to look for and appropriate treatments based on reaction severity. For mild reactions, antihistamines like Benadryl and Zantac are recommended. Moderate reactions call for IV fluids, steroids, and epinephrine. Severe reactions/anaphylaxis require aggressive IV fluid resuscitation and epinephrine, with intubation if respiratory distress persists. Glucagon is for patients on beta blockers who respond poorly to epinephrine.

1. ALLERGIC REACTIONS
(ANAPHYLAXIS)
This protocol is to be used for patients who may be
experiencing an allergic reaction. The reaction can be
triggered by contact with an object, substance, something
ingested or something injected beneath the skin (sting, bite,
IM, IV or SubQ medication or chemical, etc). The reaction
can range from a mild irritation and/or twitching (with or
without a rash) of a localized area of the skin/body, to a full
blown anaphylactic reaction with respiratory and
cardiovascular collapse.

2. SIGNS AND SYMPTOMS
• Skin – flushing, itching, hives, swelling, cyanosis.
• Respiratory – dyspnea, sneezing, coughing, wheezing, stridor, laryngeal
edema, laryngospasm, bronchospasm.
• Cardiovascular – vasodilation, increased heart rate, decreased blood
pressure.
• Gastrointestinal – nausea/vomiting, abdominal cramping, diarrhea.
• CNS – dizziness, headache, convulsions, tearing.

3. MILD REACTIONS
BASIC LEVEL: EMT and PARAMEDIC
Initial Patient Assessment Protocol 2.1.1.
Airway Assessment /Management Protocol (O2 PRN) 2.1.2.
Attach cardiac monitor and pulse oximeter.
Transport to designated hospital.
ALS LEVEL 1: PARAMEDIC ONLY
Initiate IV of Lactated Ringers or Normal Saline at TKO.
Diphenhydramine HCL (Benadryl) 25mg IV or 50mg IM (Peds; 1-2mg/kg IV or IM.
Ranitidine (Zantac) 150mg PO if able to swallow.
ALS LEVEL 2: MEDICAL CONTROL
Call Medical Control or Medical Director for any concerns or help.

4. MODERATE ALLERGIC REACTIONS
(edema, hives, dyspnea, wheezing, “lump in throat” feeling, difficulty
swallowing, facial swelling and stable vital signs with a systolic BP> 90mmHg).
BASIC LEVEL: EMT and PARAMEDIC
Initial Patient Assessment Protocol 2.1.1.
Airway Assessment/Management Protocol 2.1.2.
Attach cardiac monitor and pulse oximeter.
Transport to designated hospital.

5. MODERATE ALLERGIC REACTIONS
cont.
ALS LEVEL 1: PARAMEDIC ONLY
Initiate IV Lactated Ringers or Normal Saline at 70cc/hr.
` Diphenhydramine HCL (Benadryl) 25mg IV or 50mg IM (Peds; 1-2mg/kg IV or IM.
Ranitidine (Zantac) 150mg PO (Peds; 2mg/kg PO).
Methylprednisolone Sodium Succinate (Solu-Medrol) 125mg IV/IO/IM.
Epinephrine (1:1000) 0.4mg IM Adult (Peds 0.01mg/kg). Caution should be used with
administration of Epinephrine when the patient has a history of hypertension or heart
disease. Call Medical Control if you have any concerns.
IF patient is on a Beta Blocker medication, administer Glucagon 2mg IV over 2-5
minutes. If you are not sure which drugs are Beta Blockers, contact Medical Control to
discuss.
If a patient shows signs of respiratory distress, administer;
Albuterol (Ventolin) 2.5mg mixed with 2.5ml of Normal Saline nebulizer treatment.
May repeat twice PRN.
Add Atrovent (Ipratropium Bromide) 0.5mg to the first Albuterol nebulizer treatment
only.
ALS LEVEL 2: MEDICAL CONTROL
Call Medical Control or Medical Director for any concerns or help.

6. SEVERE ALLERGIC
REACTIONS/ANAPHYLAXIS
(edema, hives, severe dyspnea and wheezing, unstable vital signs with systolic
BP < 90mm Hg, possible cyanosis and/or laryngeal edema).
BASIC LEVEL: EMT and PARAMEDIC
Initial Patient Assessment Protocol 2.1.1.
Airway Assessment/Management Protocol 2.1.2.
Attach cardiac monitor and pulse oximeter.
Transport to designated hospital.

7. SEVERE ALLERGIC
REACTIONS/ANAPHYLAXIS cont.
ALS LEVEL 1: PARAMEDIC ONLY
Initiate IV of Lactated Ringers or Normal Saline bolus with 250cc PRN up to 1 liter
(reassess vitals and respiratory status between each bolus), then rate of 125cc/hr.
(Bolus Peds with 20ml/kg then 40cc/hr).
Diphenhydramine HCL (Benadryl) 25mg IV or 50mg IM (Peds; 1-2mg/kg IV or IM).
Ranitidine (Zantac) 150mg PO (Peds; 2mg/kg PO).
Methylprednisolone Sodium Succinate (Solu-Medrol) 125mg IV/IO/IM.
Epinephrine (1:1000) 0.4mg IM Adult (Peds; 0.01mg/kg). Caution should be used
with administration of Epinephrine when the patient has a history of hypertension
or heart disease. Call Medical Control if you have any concerns.
IF patient is on a Beta Blocker medication, give Glucagon 2mg IV over 2-5 minutes.
If you are not sure which drugs are Beta Blockers, contact Medical Control to discuss.
If patient shows signs of respiratory distress, administer; Albuterol (Ventolin) 2.5mg
mixed with 2.5ml Normal Saline nebulizer treatment. May repeat twice PRN.
Add Atrovent (Ipratropium Bromide) 0.5mg to the first Albuterol nebulizer treatment
only.
If the nebulized treatments do not significantly resolve the respiratory distress,
consider the need for intubation.

8. SEVERE ALLERGIC
REACTIONS/ANAPHYLAXIS
ALS LEVEL 2: MEDICAL CONTROL
Epinephrine (1:10,000) 0.3mg SLOW IV in 0.1mg increments over 2 minutes.
Caution should be used with administration of Epinephrine if patient has history
of hypertension or heart disease.

9. Diphenhydramine (Benadryl)
Benadryl products work because they contain an ingredient called
diphenhydramine hydrochloride, which is an antihistamine.
Here’s what happens during an allergic reaction:
• The body releases a substance called histamine into the bloodstream.
• Histamine travels to various parts of the body such as the eyes, nose, or skin.
• Histamine causes blood vessels to widen and expand.
• This causes redness, swelling, and inflammation.
• Symptoms of itching, sneezing, runny eyes or nose, or hives arise.
• The antihistamine in Benadryl blocks the action of histamine in the body and
helps to quickly relieve the symptoms.

10. Methylprednisolone Sodium Succinate
(Solu-Medrol)
• Actions: Anti-inflammatory, suppresses immune response (especially in
allergic reactions).
• Indications: Moderate and Severe allergic reaction, anaphylaxis,
asthma/COPD.
• Precautions: Must be reconstituted and used promptly. Onset of action
may be 2-6 hours and thus should not be expected to be of use in the
critical first hour following an anaphylactic reaction.

11. RANITIDINE (Zantac)
Zantac is a antihistamine primarily effective for the
histamine receptors in your stomach. They're called h-2
receptors. The histamine receptors in your blood vessels &
nerve endings are primarily h-1 receptors with some h-2
receptors. When h-1 active antihistamines like Benadryl or
Allegra are not sufficient to control hives, ZANTAC can be
added for a little extra control. Alone, it's not very good.

12. Beta Blockers
Beta blockers, also known as beta-adrenergic blocking agents,
are medications that reduce your blood pressure. Beta blockers
work by blocking the effects of the hormone epinephrine, also
known as adrenaline. When you take beta blockers, the heart
beats more slowly and with less force, thereby reducing blood
pressure. Beta blockers also help blood vessels open up to
improve blood flow.

13. Common Beta Blockers
Atenolol (Tenormin)
Metoprolol (Lopressor, Toprol-XL)
Propranolol (Inderal LA, InnoPran XL)

14. Glucagon
Glucagon bypasses the receptors obstructed by the beta-
blockers. These patients often respond poorly to epinephrine. In
case of epinephrine failure, consider the use of glucagon in
these patients.
Class: Hormone (anti-hypoglycemic agent).
Actions: Causes breakdown of glycogen to glucose.
Inhibits glycogen synthesis.
Elevates blood glucose level.
Increases cardiac contractile force.
Increases heart rate

15. Epinephrine 1:1,000
Epinephrine is a chemical that narrows blood vessels and opens
airways in the lungs. These effects can reverse wheezing, severe
skin itching, hypotension, hives and other severe allergic
reaction symptoms.